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Home My WebLink AboutGW1-2022-08253_Well Construction - GW1_20220826 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: FROM TO DESCRIPTION Well Contractor Name (0 ft. 1_ fL r _l L O l 1.a� ft V ft NC Well Contractor Certification Number i&OUTER CASING'awin 0 ' � FROM TO DIAMETERTHICKNESS MATERIAL (,tro✓A SefyC a pAA ConstrVehoo ULC { fL 3 ft in Company Name 16 INNEIZGAOtI3BiAlts; „_. ,-. a x_ � ', 3-T%0q W W PA 14 Zo FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: fL fL in. List all applicable well construction permits(i.e.UIC.County.State.Variance.err.) It. fL is 3.Well Use(check well use): 'a2:.SC8F.EI�11.= ._ Water Supply Well: I FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL Agricultural [3 unicipal/Public ft. V fL lr in 0 �{� b pie' Geothermal(HeatinglCooling Supply) iResidential Water Supply(single) fL is Industrial/Commercial 13Residentiai Water Supply(shared) x8 GROIrT " Irri tton FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ft ft "t•e Non-Water Supply Well: (9 3 '� P® Monitoring 13Recovery ft. ft lInjection Well: ft fL Aquifer Recharge 13Groundwater Rem ediation quiferStorage and Recovery Salinity Barrier FROM TO MATER14L EMPLACEMENT METHOD Aquifer Test 13 Stormwater Drainage tj f fL itz' Rvtpl CA A Experimental Technology Subsidence Control ft ft Geothermal(Closed Loop) Tracer .2QiDRMLIN6L0 attaeh 2fali sif Geothermal(Heatin Coolin Return) Crtkter(explain under21 Remarks) FROM To DESCRIPTION(eobr herancQ sorVrock etr-) Q ft. ft 14,174prow n 5!Md 4.Date Well �ns)Completed: !/i =21 Well.ID# ft. ft 12G✓ Sa.Well Location: IL fL 4 3 0h% D r}or+e It. It. Facility/Owner Name Facility ID.(if applicable) It. ft 1145 %j1Jg?;per Rd, Corolla . 27927 ft ft Physical Address.City.and bp ft ft Currrl •�u►Gk 01 A600W 32T 606 Z�•RE11'f'A .�f. -<" .,::.z - _f..,': _;.....,- 1a .--u"',,`,k"zi_i'.'.4+ County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one laVlong is sufficient) 22.Certification: It 36° 21 27 N ?S° Sl f 27 t W _r•-1/k Si L ZD ,Z 6:Is(are)the well(slar&rmanent or 13Temporary Signature ofTerti§Cd Well ntracror Date 13y signing this form.i hereby rertifi•that the iv-ell(s)was(were)romvrurred in accordance 7.Is this a repair to an eadsting well: ®Yes or 13No with 15A NCAC 02C.0100 or 15A,YCAC 02C.0200 Well Consrruction Standards and that a If this is a repair,fill our known well roratrurtion information and erplain the nature of the ropy of this record has been provided to the well nwner. repair tauter#21 remarks section or on the hark of this form. 23.Site diagram or additional well details: S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page top u;ie�Id tri3r w' Iltsiie;'d`e or well construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attack@ addilionkpSgesAn0ies drilled: SUBMITTAL INSTRUCiTONS 6 AUG 2 2022 9.Total well depth below land surface: (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths tf different(example-3@200'and 2@1001 construction to the following: x 7 �r i;_ 1MvriYi�itErl t f�..��<"nv.�� <)fiil 10,Static water level below'top of casing: 7 (ft) Division of Water Resources,Infot'mdfib1'PaNs rag Unit, ifwater level is above casing,rase" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter. (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a above, also submit one cop)' of this form within 30 days of completion of well 12.Well construction method. �w�cre construction to the following: (i.e.auger.rotary.cable,direct posh.etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 (-tt: Pk 24c.For Water Supply&Iniection Wells: In addition to sending the form to 13a.Yield(gpm) ~b Method of test: the address(es) above, also:submit one copy of this form within 30 days of 13b.Disinfection type: 1 I L Amount: I•S wu completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Qualitv-Division of Water Resources Revised 2-22-2016 'Permit- 354604 Currituck WELL PERMIT PIN: 099AO0000240003 nL r ALBEMAPLC REQIl)41L 1jr..,%1.;•H SERVKI-S Pamiecs in Ptuic Health Owner: Applicant: HARTER JOHN D HARTER JOHN D 32 COLLEGE WOODS DR 32 COLLEGE WOODS DR BRIDGEWATER,VA 22812 BRIDGEWATER,VA 22812 20' DF>RAWA,GE' aY Location: 1945 SANDPIPER RD S�� 3 , LOT 24 �„ �n .,-WELL MUST MAtN'1•AfIV jitFl�t 'MINIMUM FROM ANY - -��, ......� ....... ' PART OF'SEPTIC SYSTEWRZPAIR AREA -WELL MUST STAY AT LEAST 25 FEET FROM ANY BUILDING FOUNDATION - FOUNDATION L� ' ._. -WELL MUST 8E INSTALLED BY'A NC LICENSED WELL DRILLER •• •• •'� -WELL PERMIT MUST BE ON LOCATION OURING'ALL'PERIODS OF WELL INSTALLATION -CALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQUIRES} + INSPECTIONS OF GROUT AND WELLHEAD EX1571NC3 WELL(S) MUST BE PROPERLY AE4AN.DONED.ANO. PROPER FORM SUPIVIITTED INTO•I:HIS•OFMCE ti. '' i' a•'�� . '� rb .I �. r•'y ry• 1` •,. i5r 1 Ill ` E� S' kh .pia. ;5�'a(�/�. �.. • .-� ~ �` Yam. Permit By: i '� D,ate: 03/29/2021 Vbps, Joe Certification By: Date: Construction has been completed, a Residential Well Construction Record Form GWAa has been submitted and inspections have been completed in accordance with 15 A NCAC 02C.0300. t� rvf..t!" � DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC HEALTH Roy COOPER MANDY COHEN,MD,MPH GOVERNOR SECRETARY MARK BENTON DIRECTOR Onsite Water Protection Branch July 25,2022 John D.Harter 32 College Woods Dr. Bridgewater,VA 22812 RE: Approval No.WWM1430 Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C .0116 1945 Sandpiper Rd. Corolla,NC 27927 On July 25,2022,the On-site Water Protection Section received your request to approve construction of a well obtaining water from a depth less than 20 feet in an area not covered by 15A NCAC 02C .0116(b). The approval request is for the construction of one(1) water supply well at 1945 Sandpiper Rd.,Corolla,NC. In your request,you indicated that due the inability to obtain potable water at deeper depths,a shallow well was the most reasonable option at this property. Based upon available information provided by Albemarle Regional Health Services staff,you are approved to construct a well obtaining water from a depth less than 20 feet below land surface,in conformity with the requirements of 15A NCAC 02C .0116(c)(3),that will serve the above referenced site. A copy of this approval should be attached to the required Well Construction Record(GW-1)as well as the county well permit at such time that it is issued. Furthermore, it is strongly recommended that you sample your well annually for bacteriological contamination,as shallow wells can be more susceptible to bacteria. The approval of this variance does not affect any of the other requirements or limitations of the Well Construction Standards, including but not limited to the requirements in 15A NCAC 2C .0113(b)to repair or to abandon any well which acts as a source or channel for the migration of contamination or to your responsibility to comply with any other applicable Federal, State,or local laws or regulations. The granting of this approval is for the well location only,and in no way relieves the owner or agent from other requirements of the North Carolina Well Construction Standards,or any other applicable law,rule,or regulation that may be regulated by other agencies, nor does it imply sufficient water quality. If you have any questions regarding this variance,please contact Wilson Mize at(919)-270-9665 Sincerely, Wilson Mize R.E.H.S. WWW.NCDHHS.GOV TEL 919-707-5874•FAx 919-845-3972 LOCATION:5605 SIx FORKS RD•RALEIGH,NC 27609 MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER